Military Medicine最新文献

Delayed pressure urticaria (DPU) is a subset of chronic inducible urticaria. It is characterized by the formation of wheals anytime between 30 minutes and 24 hours after stimulus exposure of localized pressure application. In this case report, we discuss a military flight crew member with no significant past medical history who developed DPU following rapid decompression in an altitude chamber. The chamber training included an uneventful ascent to 45,000 feet, higher than he had been previously, and a rapid decompression. About 16 hours later, he developed pruritic swelling of his hands and feet, along with diffuse deep nodular swelling, erythematous plaques, and erythematous nodules. His DPU was refractory to monotherapy treatment with antihistamines, and he continued to develop lesions in weight-bearing areas. Control of symptoms was achieved through combination treatment of a second-generation antihistamine, a leukotriene receptor antagonist, and an immunosuppressant (cyclosporine). His waiver to return to flight status was denied while on cyclosporine. He was transitioned to a monoclonal antibody that binds free immunoglobin E (omalizumab) with resolution of symptoms and was cleared to return to active duty.

An internal medicine resident from Naval Medical Center San Diego uses poetry to contemplate how easily a future can be ended for an aspiring warfighter. This poem explores the power of military physicians to end a career and how distressing the process is for patient and doctor alike.

Introduction: The neurobehavioral significance of white matter hyperintensities (WMHs) seen on magnetic resonance imaging after traumatic brain injury (TBI) remains unclear, especially in Veterans and Service Members with a history of mild TBI (mTBI). In this study, we investigate the relation between WMH, mTBI, age, and cognitive performance in a large multisite cohort from the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium.

Materials and methods: The neuroimaging and neurobehavioral assessments for 1,011 combat-exposed, post-9/11 Veterans and Service Members (age range 22-69 years), including those with a history of at least 1 mTBI (n = 813; median postinjury interval of 8 years) or negative mTBI history (n = 198), were examined.

Results: White matter hyperintensities were present in both mTBI and comparison groups at similar rates (39% and 37%, respectively). There was an age-by-diagnostic group interaction, such that older Veterans and Service Members with a history of mTBI demonstrated a significant increase in the number of WMHs present compared to those without a history of mTBI. Additional associations between an increase in the number of WMHs and service-connected disability, insulin-like growth factor-1 levels, and worse performance on tests of episodic memory and executive functioning-processing speed were found.

Conclusions: Subtle but important clinical relationships are identified when larger samples of mTBI participants are used to examine the relationship between history of head injury and radiological findings. Future studies should use follow-up magnetic resonance imaging and longitudinal neurobehavioral assessments to evaluate the long-term implications of WMHs following mTBI.

Introduction: The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework.

Materials and methods: This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system. The project design applied a pre-post quasi-experimental design that examined within-cohort changes at pre-intervention, intervention, and 2 post-intervention follow-up timepoints. HRO interventions included a combination of training, leadership coaching, site assessments, and experiential learning. HRO interventions were initiated at 18 facilities beginning in 2019 (Cohort 1), 54 facilities in 2020 (Cohort 2), and 67 facilities in 2021 (Cohort 3). For between-cohort analyses, the relative degree of change within Cohort 1 sites was compared with all other sites.

Results: There were broad positive within-group trends for PSC scores across all sites, and domain-specific between-group differences in PSC Dimension 2-Risk Identification and Just Culture-and Dimension 4-Error Transparency and Risk Mitigation. For patient safety reporting, total events reported, and close calls increased for Cohort 1. The ratio of close calls to adverse events also increased for both Cohort 1 and all other VHA sites at post-intervention year 2.

Conclusions: The results of this QI project will inform further refinements to VHA's efforts to implement HRO principles and practices in the nation's largest integrated health system. In addition, the implementation practices may inform other large-scale, multi-level efforts to improve quality and patient safety.

Introduction: The military employs a wide variety of training paradigms to prepare a ready medical force. Simulation-based training is prominently used in the military for all roles of care to provide the knowledge, skills, and abilities needed to render care from the battlefield to the hospital. The purpose of this scoping review is to synthesize the body of research in military healthcare simulation, highlight trends in the literature, and identify research gaps.

Materials and methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis process, the databases of PubMed, Google Scholar, and targeted conferences were searched for articles focused on simulation-based training in the military healthcare community. Inclusion criteria required that the studies assessed a healthcare simulation intervention and had military participants. Data were gathered on population parameters (branch of service and provider level) as well as study parameter (simulation modality, medical domain, and outcome measures). Outcome measures were categorized according to the Kirkpatrick model of training evaluation.

Results: A total of 43 articles met inclusion criteria. Article summaries and descriptive data on the participant populations and study parameters are provided in Tables 1, 2, and Supplementary Table S1.

Conclusions: Participant populations were inclusive of all the services and roles of care, suggesting appropriate representation of the broad military healthcare community. The majority of literature has studied physical simulations, such as manikins or task trainers. Few studies employed augmented or virtual reality as the training intervention, likely because of the nascency of the technology. Trauma care was the focus of 65% of the studies; this is attributable to the criticality of trauma care within battlefield medicine and casualty response. Related to study outcomes, participant reactions, such as usability and user acceptance, and immediate learning outcomes were heavily studied. Retention and behavioral changes were rarely studied and represent a significant research gap. Future research assessing mixed reality technologies would be beneficial to determine whether the technology warrants inclusion in programs of instruction. Finally, studies with outcome measures including long-term knowledge and skills retention, behavioral change, or patient outcomes are strongly recommended for future research.

Acute coronary syndrome (ACS) is a rare cause of chest pain in adolescents and young adults. Kawasaki disease (KD) is an uncommon illness, but coronary artery aneurysms secondary to KD are implicated in approximately 5% of cases of ACS in young adults. Patients with KD may present with catastrophic coronary disease at a young age and thus early recognition of this disease process and lifelong follow-up is essential. Here we discuss a 19-year-old active duty male with no previously recognized medical history who presented with crushing chest pain while deployed. He was diagnosed with an ST elevation myocardial infarction and was found to have a giant aneurysm of the left main coronary artery with obstructive thrombus treated with emergent thrombectomy and balloon angioplasty. He developed cardiogenic shock requiring mechanical circulatory and ventilatory support. After a prolonged recovery and more in-depth history-taking, he was discovered to have been diagnosed with KD as a child without follow-up. Diagnosing ACS in young adults can be challenging, but a history of KD should increase suspicion for coronary disease. This case demonstrates the importance of screening after a childhood diagnosis of KD, specifically when caring for the tactical athlete. It also highlights the impact that social determinants of health can have on patient outcomes. Finally, it demonstrates the importance of communication and coordination between military and civilian medical centers across the globe driving the care of our deployed injured and ill active-duty military personnel.

Objective: To understand the mechanisms of injury and demographic risk factors associated with traumatic brain injury (TBI) patients among active and reserve service members in the U.S. Military before and during the COVID-10 pandemic.

Methods: Active and reserve service members diagnosed with an incident TBI from January 2019 through September 2021 were selected. Traumatic brain injury patients diagnosed before March 1, 2020 were categorized as pre-COVID (PC), and patients diagnosed on or after March 1, 2020 were categorized as the intra-COVID (IC) group, aligning closely with the date when the World Health Organization officially proclaimed the pandemic. We determined the frequency of causes of injuries associated with TBI separate by sex, age, occupation, and TBI severity. In addition, we conducted multivariate logistic regression analyses to assess the demographic risk factors associated with TBI severity during the PC and IC eras.

Results: Our cohort included 48,562 TBI patients: 22,819 (47.0%) diagnosed during the PC era and 25,743 (53.0%) diagnosed during the IC era. The major mechanisms of injury within our TBI cohort were being struck by/against objects, falls/slips/trips, and motor vehicle traffic accidents before and during the pandemic. The most common causes of TBI were not impacted by COVID, but motor vehicle accidents did increase during the IC era. The mechanisms of injury associated with TBI differed by TBI severity: being struck by or against an object caused more mild and moderate TBI; motor vehicle accidents caused more severe TBI; and firearms was a major cause of penetrating TBI. In addition, the percentage of severe TBI because of firearms rose sharply during the IC era. Further, women were more likely to be diagnosed with mild TBI compared to men.

Conclusion: Military leaders should consider how different causes of injury are associated with differing TBI severities and how certain demographic groups were vulnerable to specific TBI severities when developing injury prevention programs.

Introduction: Teledentistry, also known as "virtual" dental examinations, is an innovative approach to increasing access to care. The objective of this study was to evaluate the diagnostic inter-rater reliability between virtual and in-person examinations for patients seeking emergency dental care (sick call) at a military dental treatment facility.

Materials and methods: One hundred subjects received both virtual and in-person examinations on the same day, in random order. The virtual examiner and subject were stationed in separate rooms and used only a laptop equipped with a camera, microphone, and speaker to complete the virtual exam. In contrast, the in-person examiner had access to all standard care modalities in a dental treatment room. After the first encounter, the subject proceeded to the corresponding virtual or in-person exam, and both examiners determined a diagnosis. Inter-rater agreement was determined between the two encounters for both diagnosis specialty category and diagnostic code using the Kappa coefficient.

Results: The results of the inter-rater analyses showed a Kappa score of 0.644 for the diagnosis specialty category (P < .001) and a Kappa score of 0.714 for diagnostic codes (P < .001). Both analyses indicated "substantial" agreement.

Conclusions: We conclude that teledentistry can be an effective tool for determining a diagnosis and improving access to care for dental emergencies at military dental treatment facilities.